A CASE LIKE NO OTHER

Report into baby Simeon’s death:

The committee probing the death of baby Simeon Cottle, who died after his head was cut during Caesarian surgery at Mt Hope Women’s Hospital three months ago, has said it can find no other case where this occurred in any medical journal.

The committee’s report has said baby Simeon’s injury occurred from failure to exercise the degree of skill which was required in order to perform the surgery.

A prima facie case of medical negligence may have been made out following Dr Javed Chinnia’s admission a surgical error was to be blamed for the death.

And while complications may arise during a Caesarean section, the iatrogenic injury baby Simeon sustained during delivery on March 1 could have been prevented if proper procedures and standards were followed.

These were some of the findings of an independent committee—comprising chairman and retired Appeal Court judge Mustapha Ibrahim, neonatologist Dr Petronella Manning-Alleyne and consultant obstetrician/gynaecologist Dr Melanie Clare Davis—set up by Attorney General Anand Ramlogan to investigate the circumstances into the death of baby Simeon.

Based on the findings, the committee has advised the medi­cal disciplinary authorities as constituted under the Medical Board Act Chapter 29:50 should determine the necessary course of action in this case.

In a March 9 quality report sent to Health Minister Dr Fuad Khan containing statements about the incident, and obtained exclusively by the Sunday Express, Dr Chinnia listed the nature of the event as a “surgical event/surgical error”.

According to the committee, Chinnia’s description of the incident as a “surgical error” is an admission of negligence.

The June 6 report submitted by the committee said: “This admission of a surgical error is an admission of a prima facie case of negligence. There was no suggestion that what happened to infant Cottle was the kind of thing which might happen if due care was taken. But no such submission could have been made because the degree of negligence was of a very high order.”

The independent committee also noted conflicting statements surrounding the length of the laceration to the skull of baby Simeon.

The report said: “There was an issue as to the length of the laceration with Dr Chinnia stating that it was about four centimetres long but the pathologist (who measured it) stated in his report that it was seven centime­tres long. Dr Ranghell, a paediatrics haematologist/oncologist, stated it was seven centimetres long and there was active bleeding in addition to a punctured wound to the skull.

“We are of the opinion that having looked at the photographs and taking into account the opinions of Dr Ranghell and the pathologist it (the laceration) was seven centimetres in length. Quite apart from the admission of Dr Chinnia, the nature of the injury sustained raises the issue of negligence which could not have been answered.

“In this case it is clear that the injury occurred from failure to exercise the degree of skill which was required in order to perform this procedure. There is no case that can be identified in any reputable journal in which a case similar to this one has occurred.”

Unsatisfactory health care

The committee concluded the death of baby Simeon was due to iatrogenic injury sustained during delivery by Caesarean section, compounded by inadequate management of the infant after birth.

“The iatrogenic injury to the foetus occurred during Caesarean section. This was a surgical accident, and although injury to foetus is a recognised complication of Caesarean section, there is no report in the medical literature of an injury of this specific nature, which incised through the foetal scalp and skull to involve the parietal lobe of the brain. The extent of this injury indicates that the skill exercised during this delivery fell short of the standards expected of a trained and competent practitioner. There was a lack of involvement of senior obstetric staff with failure of the consultant-on-call to provide appropriate support,” the report concluded.

Baby Simeon sustained a cut to his head while his mother, Quelly Ann Cottle, was undergoing a Caesarean section.

He died hours later.

The committee also disagreed with how the incident was handled.

The quality report quoted Chinnia’s description of the incident as: “A Caesarean section was being performed for delivery as there was severe intrauterine growth restriction. Routine procedure was followed. The lower uterine segment was first incised using the scalpel. The incision was opened with blunt dissection using a small artery clip. On delivering the foetus a laceration three to four centimetres was observed across the scalp. The paediatrician present was informed immediately as to was the patient (sic).”

Inadequate treatment

The committee, however, frowned upon the treatment administered to the injured baby. “Inadequate measures were taken to manage the infant and to replace blood lost. The paediatric registrar and consultant appeared unable to recognise the need for their presence and to provide appropriate support,” the report said.

The committee further noted that in the 21st century, substandard health care is unacceptable. “We have to come to terms with the fact that an educated and exposed population does not expect the medical care professionals to continue to stumble and fumble around with their children’s very lives and future.

“The neonate continues to be the pro­vince of the neonatologist. We will not expect the general practitioner to exhibit the same level of skills in handling paediatric neonate as the paediatrician can. The cardiologist will not do as well in oncology as the oncologist. So the paediatrician should not be expected to exhibit the same competency in dealing with the neonate as the neonatologist. Administration must engage the proper skills to deal with the neonate,” the report said.

Twenty-seven witnesses appeared before the committee, including Quelly Ann Cottle.

The committee, however, noted all the witnesses except registrar/paediatrics Dr Nishal Persad cooperated with the investigation.

Persad, the committee said, could have assisted with seve­ral matters, but his attorney (name withheld by the committee) advised he had already given a statement to the authorities and had nothing more to add on the matter.

Prime Minister Kamla Persad-Bissessar on Thursday appointed a Cabinet committee to look at the report into the death of baby Simeon.

• The consultant on-call should be involved in all cases involving mortality or serious morbidity. Following a serious adverse event, the consultant should see the patient/parents involved. The consultant should provide support for the team involved in a traumatic event;

• Laboratory services are required around the clock; the availability of blood for transfusion is a priority;

• Clinical guidance protocols which address clinical management of all aspects of care of the mothers and babies should be developed;

• There must be adequate on-site supervision for all junior medical staff;

• There should be daily consultant presence on the maternity wards. The consultant on-call each day should undertake a formal morning ward round to review high-risk patients in delivery suite, antenatal and postnatal wards;

• Planned high-risk deliveries should be booked within weekday working hours where possible, to ensure that staff and resources are available. This applies to both maternal and foetal indications. However, clinical need is paramount.

• Planned deliveries should not be restricted to on-call days;

• A second dedicated obstetric theatre is required. This would facilitate a greater possibility of having planned deliveries in a timely manner;

• Immediate review of resuscitation procedure with special emphasis on the response to acute blood loss and the use of adrenaline and sodium bicarbonate;

• Immediate provision of training in the care of small/tiny neonates with special emphasis on the infusion of flui­ds: quality, volu­me and rate; and

• Employ the appropriate professio­nals to deal with and to support the needs of neona­te.

Flashback

The March 9 quality report was forwarded to the Attorney General by the Health Minister after disagreement between the Dr Shehenaz Mohammed-led North Central Regional Health Authority (NCRHA) board and The University of the West Indies (UWI) as to who was to blame for baby Simeon’s death.

The UWI defended its consultants as well as Dr Chinnia, saying he had a successful record of 100 surgeries and required no supervision. The NCRHA, however, questioned the absence of consultants Dr Bharat Bassaw and Dr Mary Singh-Bhola, who were listed on duty, and why Dr Chinnia was left unsupervised duri­ng the surge­ry.

The hospital roster obtained by the Sunday Express listed that Dr Bassaw was to proceed on a leave of absence with effect from March 1 to 3. As a result, Dr Bassaw should not have been rostered for duty.

Dr Singh-Bhola has maintained she was available and accessible for on-call advice, assistance as needed.

She was informed of baby Simeon’s injury via telephone.

Case for litigation

Based on the evidence, it appears as though civil litigation for a case of medical negligence may have been made out against Dr Chinnia and the hospital.

According to former attorney general Ramesh Lawrence Maharaj, there can be a claim by an individual for damages for medical negligence if a doctor, hospital or nursing home acts carelessly without administering the proper health care, resulting in negligence which results in death or injury. Maharaj said if the medical negligence causes death then the individual can be prosecuted for manslaughter.

“If the family of the deceased is dissatisfied with the police not taking action when there is evidence of manslaughter, the family can apply to the Magistrates’ Court and produce evidence to the magistrate for a private indictable criminal information to be laid against the individual,” Mahar­aj said.